Patient Care Access News

Why Patient-Centered Care Coordination Must Start with PCPs

Patient-centered care coordination is critical in the shifting healthcare industry, and primary care providers must recognize the important role they play in providing it.

By Sara Heath

As value-based reimbursement makes patient-centered care coordination a serious financial advantage, primary care providers must take on a greater role in patient management and preventative care delivery.  


Becoming a centralized hub for care allows PCPs to foster strong patient engagement relationships, coordinate service, and manage chronic diseases as they move beyond the scope of traditional medicine.

By delivering quality care in all of these three aspects, providers can ensure better patient engagement and more patient-centered care, which in turn will ideally lead to higher levels of patient wellness.

The epicenter of care coordination

Patients view primary care as exactly that: the central place where they receive their healthcare. Because of this, primary care providers need to zero in on care coordination as a way to ensure patient satisfaction with the primary care and as a way to ensure that patient care is comprehensive when they visit specialists.

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A 2015 Accenture survey investigated patient preferences with primary care coordination, showing that a majority of patients want their care managed at one central point. Eighty-seven percent of respondents reported such, and a near equal number of respondents reported that their primary care providers should be the epicenter of all of this care coordination.

Patient-centered care coordination is not just limited to how primary care providers and specialists can manage an individual patient. This concept also extends to how providers can coordinate care with the patient, engaging them in their own care.

According to Marcia Cheadle, RN, Senior Director of Clinical Applications at Inland Northwest Health Services, patients need to be integrated as a member of the care team. This means that they participate in care coordination efforts.

“By having more patient involvement, that activation of the patients in their care journey, their longitudinal healthcare journey, we’re really looking to leave behind that unilateral decision-making, that white coat paralysis that happens to all of us when go in to see the doctor,” Cheadle said.

Cheadle says patients can be brought into the care team through digital technologies, mainly patient portals. By giving patient access to their health data, they stake a bolder claim in their healthcare. Additionally, they can contribute their own patient-generated health data, adding to the repository of information a primary care provider may have.

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Primary method for early disease detection

As primary care providers generally tend to patients’ overall wellness, their practices are ideal for detecting illness early on, hopefully mitigating those illnesses before they become catastrophic.

Primary care providers must deliver patient-centered care as a means to better detect patients’ illnesses in early stages. According to Mark Wagar, President of Heritage Medical Systems, this is the main goal of primary care.

“It’s not enough to be really good when somebody falls in your door,” Wagar asserted. “It’s in fact as important, if not more important, to be able to figure out how to work with them to improve their general health status so that they have fewer events where they fall in the door.”

Patient engagement is vital for providers to really determine what may be ailing a patient, and then conduct further tests to potentially uncover a chronic disease.

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Engagement goes beyond the realm of patient-provider communication in the primary care site, however. According to Peter Goldbach, MD, Chief Medical Officer of RediClinic and Health Dialog, being able to early detect chronic diseases starts with getting the patient in the door. An innovative approach to this is through primary care delivery in retail clinics.

Retail clinics make good healthcare more accessible as well as affordable for a broad group of Americans, which means people get the care they need a return to health faster,” he noted.

Retail clinics also help patients who have already been diagnosed with a chronic disease receive care coaching in convenient locations.

“We’re going to be moving toward a provision of chronic care because if you think about a lot of what’s been written about chronic care and how we’re looking to improve it and keep care coordinated, a lot of that centers on patient-centered medical homes,” Goldbach said.

“The way I think it’ll play out is that ACOs will embrace retail as the right solution for them. It’ll allow them a larger primary care footprint, it’ll allow them to deliver care more efficiently.”

Moving beyond the scope of traditional medicine

Unlike specialist care, primary care practices enable physicians to go beyond one specific ailment. When a patient visits their primary care doctor, they not only care for the patient’s overall wellness, but also probe into other aspects of the patient’s life that could affect that wellness.

While providers can certainly deliver quality technical healthcare, it’s the going beyond that which allows providers to deliver better care in the future.

“Certainly we have all the necessary delivery systems to take care of you when you come to us in a physician's office or in an urgent situation… where you have determined that you need something, you’re really sick, you’re injured, we have all that,” Wagar stated.

“That’s the traditional healthcare system. It’s the engagement with you when you’re not presenting technically as a patient today that is the key.”

Primary care providers can go beyond the traditional scope of medicine to understand what about a patient’s personal life may bar them from actually attending their doctor’s appointments. From there, providers can mitigate these issues. All of these actions go specifically with accountable care organizations, which by definition deliver highly patient-centric care.

“It’s a matter of adapting your outreach to what will work for [the patient],” Wagar explained. “Maybe if they live in an apartment building in an urban setting, maybe they have a couple of friends who are the best persons to talk with them and help us get information and figure out the best way to access them. If someone’s relatively isolated, get some kind of community care worker, a local person they trust to visit once in awhile.”

As the healthcare landscape changes to value patient-centered care over the volume of care delivered, primary care providers will need to recognize that they are the central place where this transition can begin.

By understanding the role that primary care plays in delivering patient-centered care, these physicians can better utilize care coordination and chronic disease management and detection strategies to move beyond the traditional scope of care.


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